Reducing the Stigma: Faculty Speak Out About Suicide Rates Among Medical Students, Physicians

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The young physician was so critically depressed that the family cat would not come near him, according to the doctor’s wife. She felt safe disclosing this to Jay Lynch, MD, a professor of medicine at the University of Florida College of Medicine, because he is one of a very few physicians to publicly reveal struggles with depression and suicidal thoughts. Lynch has shared his story on KevinMD.com; NPR’s Weekend Edition; and TheConversation.com.

Higher suicide rates among physicians than in the general population are widely documented. How much higher is not clear because solid data are lacking, experts agree. But Srijan Sen, MD, PhD, an assistant professor of psychiatry at the University of Michigan Medical School and the principal investigator of the Intern Health Study, a longitudinal study of depression among interns nationwide, estimates “suicide rates among physicians are something like 40 to 70 percent higher in males and 130 to 300 percent higher in women.”

Among medical students, suicide is the second most common cause of death, after accidents. A study published in the February 2009 issue of Academic Medicine found that 13.6 percent of medical students exhibited probable major depression and 6.6 percent reported suicidal ideation.

Lynch shared his own experience with depression and suicidal thoughts in 2014 after two interns in New York City jumped to their deaths within days of each other. He explained that a dozen years earlier as a physician in his 40s, his life had all the trappings of success but he was depressed.

“[Depression] is a malignancy of the mind,” he observed. “It disables our ability to see it in ourselves.” He got as far as planning how to make his death appear to be an accident rather than suicide.

What pulled him back from the brink was a friend’s expression of concern. In 2002, at the funeral of a college classmate, Lynch’s friends talked about struggles in their lives. “I sat mute, listening,” Lynch wrote on TheConversation.com. “Then one of my friends turned to me and asked, ‘How about you, Jay? You’re awfully quiet.’ I knew I finally had a chance to be honest.… I muttered something like ‘Not too well, I think.’”

As soon as he got home from the funeral, Lynch called a psychiatrist friend. “She asked me, ‘What is it you’re so afraid of?’ I said, ‘All I do is disappoint people.’... As false as that was objectively, that’s the way everything felt.” But his turnaround was swift. “My response to antidepressants was so dramatic, it’s hard to articulate it,” he said. “Within seven to 10 days, I felt like a new person.”

Physicians’ medical knowledge does not make them immune from the stigma of suicide. Last fall, Lynch decided to tell his story to help break the logjam of silence. “It shouldn’t be that this is such a taboo subject in an era when anybody who knows anything about physiology realizes that neurotransmitters and neural networks are how we think and feel,” he said.

Similarly, medical schools across the country are addressing the issue head-on. “Increasingly, schools are sensitive to the fact that there are students who may be at risk,” said Geoffrey Young, PhD, AAMC senior director for student affairs and programs.

At the same time, general wellness is receiving growing attention, with AAMC-member institutions “educating student communities, as well as faculty and administrators, about the importance of work-life balance,” Young noted. He cited advising and mentoring structures, such as the Indiana University School of Medicine’s College and House program, as “a safety net” for students. In addition, Vanderbilt University School of Medicine has numerous extracurricular activities that give students downtime and a chance to socialize.

“Students should participate in activities outside of medicine, maintain personal connections, and make their own physical health a priority,” said Scott Rodgers, MD, former associate dean of student affairs at Vanderbilt.

Since Lynch revealed his own safety net, he has heard from more than 100 people moved by his story. One was the wife of the physician with depression so deep that the cat sensed it. About a month later, Lynch said, the physician’s wife told him that her husband was “not perfect but he’s better—and the cat sits in his lap now.”

Reasons for the higher suicide rate

Physicians and medical students typically are slow to understand their anguish. “Physicians are very cautious about acknowledging these feelings and about getting help,” said Diane Roston, MD, a clinical assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine. “Physicians often struggle with these thoughts all by themselves for much longer [than non-physicians],” she said.

The reasons for this paint a distinctive picture of depression. One, ironically, is that physicians can be even more susceptible than non-physicians to feeling shame about suicidal thoughts. “It’s a proud population,” said John Greden, MD, executive director of the University of Michigan Comprehensive Depression Center and past president of the American Foundation for Suicide Prevention. “It’s not part of the culture. We don’t want to acknowledge vulnerabilities; we’re supposed to be on top of everything.”

Another factor, Lynch noted, is that physicians, more than people in other professions, fear that admitting to suicidal thoughts will affect their livelihood. “They’re often afraid they won’t be able to practice, they’ll lose privileges,” he said.

While that fear may be imaginary, two very real aspects of physicians’ work also play into their hesitation to seek help. First, the stress and emotional intensity of caring for others can render physicians less able to care for themselves. Medicine is “a tough job, and the responsibility of caring for patients can be an overwhelming job,” Young pointed out. Second, carving out time for treatment from a busy clinical schedule proves insurmountable for some physicians.

In addition, physicians have more knowledge than the general public about effective means to achieve death. “If the attempt is lethal,” Greden noted, “you don’t get a second chance.” This factor is credited as the reason female physicians have a higher rate of suicide, compared with women overall. In the general public, more women than men attempt suicide, but men are more apt to choose a lethal method. Women physicians, however, know just as well as their male peers how to take their lives.

The most important factor in physicians’ higher suicide rate is their “fearlessness about the physical ordeal” of death, explained suicidologist Thomas Joiner, PhD, the Robert O. Lawton Professor of Psychology at Florida State University. Humans’ fear of death “is deep in our DNA,” he said. “[Fear is] a huge barrier to death. It happens every day that people are consumed with the idea of suicide up until the very last instant when that fear kicks in and saves them.”

Roston, too, believes fearlessness is the principal factor in the suicide rates of physicians. “No matter what field of medicine you’re in, you’ve had exposure to physical trauma, and that desensitizes you to blood and injury and toxicity,” she said. That is why, she and others noted, police officers, firefighters, EMTs, nurses, and members of the military also have higher than average suicide rates.

Search for solutions

Despite the apparent complexity of the problem, experts suggest down-to-earth solutions such as talking about the problem, normalizing it to dispel the stigma, reaching out to troubled colleagues, and taking care of one another.

One essential step is shining the light of day on the issue through more physicians telling their stories, according to Lynch. “If enough people come forward, there will be more who will be willing to acknowledge their struggles,” he said.

Recognizing that depression is a disease is very important, Young noted. “Try to reduce the stigma and create an environment where [depression] isn’t viewed as a weakness,” he said. That type of environment is the rationale for initiatives such as the Mayo Clinic’s Physician Well-Being Program, which provides resources to promote wellness and fosters personal and organizational approaches to preventing physician distress.

Medical schools and teaching hospitals are actively working to prevent suicides by cultivating a learning environment that is supportive when mental health issues arise. Many are educating students and faculty about the risk factors and warning signs that could precede suicidal thoughts. In addition, there has been a push to screen for fatigue and burnout throughout the education continuum and during medical practice.

The Accreditation Council for Graduate Medical Education requires that programs provide confidential counseling for trainees who may be experiencing suicidal ideation. To ensure anonymity, medical schools have implemented policies that separate mental health services from the academic environment.

Approaches should include “making it clear that [the problem] won’t affect people’s careers and licensing,” Sen observed. Those struggling with depression “often think they’re alone,” he added. “If people would realize that many of their colleagues and friends are going through this as well, they could help support each other in better ways.”

"If people would realize that many of their colleagues and friends are going through this as well, they could help support each other in better ways.”

— Srijan Sen, MD, PhD

Such support can be as low-key as asking colleagues if they are okay. Greden compared it to a peer-to-peer model that has been successful in getting military veterans to seek mental health care. “We trust each other, we take care of our own” is the way veterans explain it, Greden said. “These are conditions that are treatable, but not if the person doesn’t get treatment. That’s the biggest hurdle we face.”

The key is “to get people talking, so they realize, ‘Oh, I’m not alone,’” Lynch said. “That first crack in the door can come from anybody they trust. A trust factor has to be part of this.”

 

This article originally appeared in print in the September 2015 issue of the AAMC Reporter.